ORIGINAL ARTICLE

Pterygium Recurrence Related to its Size and

Corneal Involvement
Pir Salim Mahar and Nabeel Manzar

ABSTRACT
Objective: To establish the usefulness of grading system based on the size and extent of corneal involvement in predicting
recurrence in patients undergoing primary pterygium excision with intraoperative use of adjunctive topical Mitomycin-C
(MMC).
Study Design: A case series.
Place and Duration of Study: Section of Ophthalmology, the Aga Khan University Hospital, Karachi, from 2005 till 2010.
Methodology: One hundred and twenty male patients (120 eyes) underwent surgical removal of pterygium using bare
sclera method with MMC in concentration of 0.2 mg/ml (0.02%) with exposure time of 3 minutes. Classification of subjects
was done according to the grading of pterygium. Patients were followed at 3 months interval for a minimum period of 1
year to record any recurrence.
Results: The pterygium recurrence rate was 6.7% at a follow-up of 1 year. There was no significant association of
pterygium recurrence with younger age (p = 0.14). A higher level of corneal involvement by the pterygium at presentation
correlated significantly with the recurrence (p = 0.01).
Conclusion: These results suggest that a higher grade of pterygium at presentation in patients leads to increased rate of
recurrence after surgical excision. Hence, early excision of pterygium is recommended to decrease its recurrence rate.
Key words:

Pterygium. Recurrence. Grading system. Size. Corneal involvement.

INTRODUCTION
Pterygium is one of the most common conjunctival
surface degenerative disorders.1-3 This fibrovascular
expansion of bulbar conjunctiva over the limbus, leads to
chronic irritation, impaired cosmesis, irregular astigmatism and decreased vision secondary to the development
of pupillary axis blockage by the increased growth.2
Different surgical techniques have been used for the
management of pterygium. The most common has been
the Ombrian's bare scleral excision technique.4
However, the major limitation to the success of the
technique has been the high rate of postoperative
recurrence associated with it.5
A number of adjunct therapies with varying levels of
reported successes have been used along with bare
scleral excision during the last three decades. Mitomycin-C
(MMC) as an adjunct therapy to bare sclera technique
was first introduced by Kunitomo and Mori of Japan.6
Further works on MMC usage in the USA by Singh and
associates led to its widespread use in Asia.7 A relatively
new method being used for pterygium management has
been the conjunctival autograft method. However, the
Section of Ophthalmology, Department of Surgery, The Aga Khan
University Hospital, Karachi.
Correspondence: Dr. P. Salim Mahar, 34/1, Khayaban-e-Mujahid,
Near 22nd Street, DHA, Phase V, Karachi.
E-mail: salim.mahar@aku.edu
Received January 15, 2011; accepted November 13, 2012.
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reported pterygium recurrence rates for the two

techniques are comparable (2 39%).8,9 Despite these
comparable recurrence rates the use of topical
Mitomycin-C (MMC) as an adjunct therapy to bare sclera
technique to prevent pterygium recurrence is widely
used in Asia.
A number of research studies have been carried out to
document the influence of age, gender, appropriate
dosage of mitomycin-C (MMC) in treating pterygium and
preventing its recurrence.10-12 However, relatively few
studies have evaluated the role of grading system based
on the size and extent of pterygium encroaching on the
cornea, especially in the context of the local population
of Asia where there is high prevalence of pterygium. The
purpose of the study was to establish the usefulness of
grading system based on the size and extent of corneal
involvement in predicting recurrence in patients
undergoing primary pterygium excision with intraoperative use of adjunctive topical Mitomycin-C (MMC).

METHODOLOGY
This case series study was carried out at Ophthalmology
Department, the Aga Khan University Hospital (AKUH),
Karachi, Pakistan from 2005 till 2010. The study protocol
was reviewed and approved by an ethics committee at
the study centre and the study was carried out in
accordance with the declaration of Helsinki of 1975 as
revised in 1983. The primary outcome measure was the
comparison of pterygium affected eye for any kind of
recurrence after excision along with the assessment of

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (2): 120-123

Pterygium recurrence related to its size and corneal involvement

the potential role of a grading system based on the size

and extent of corneal involvement in pterygium
recurrence after a minimum of 12 months of follow-up.

significance of recurrence among different groups based

on age and grading of pterygium. A p-value of < 0.05
was considered as significant.

Only those patients fulfilling the following criteria were

enrolled in the study: informed consent from the patient,
male patients of all ages with established diagnosis of
unilateral progressive primary pterygia of different
grades, supervised surgical excision by bare scleral
technique and MMC administration with a minimal
follow-up period of 12 months. Patients lost to the followup or having any suspicious growth other than pterygia
and corneal scarring were excluded.

RESULTS

All patients had their detailed medical history taken, with

complete ocular examination including best corrected
visual acuity (BCVA), bio-microscopic examination of
anterior segment with Goldman applanation tonometry
and fundus examination with +90DS lens.
Pterygia were graded depending on the size and extent
of corneal involvement by the principal investigator
(PSM) to minimize any bias due to inter-rater variability
as follows: grade 1 - between limbus and a point midway
between limbus and pupillary margin, grade 2 - head of
the pterygium reaching the pupillary margin (nasal
papillary margin in case of nasal pterygium and temporal
margin in case of temporal pterygium) and grade 3 crossing pupillary margin.3,13
Pterygium excisions were performed on an outpatient
basis by the same surgeon using the same technique.14
After excision with bare scleral technique under topical
anaesthetic (Proparacaine- Alcon, Belgium), a sterile
sponge (5 x 5 mm) soaked in 8 10 drops of 0.2 mg/ml
MMC (0.02%) (Mitomycin-C, Kyowa - Japan) was
applied over corneo-sclera and the area from where
pterygium was excised with a fixed time duration of 3
minutes to remove any bias due to different MMC
application time. The sponge was removed and eye
irrigated with 20 ml of normal saline 0.9%. This was
followed by topical administration of Dexamethasone
0.1% + Tobramycin 0.3% (Tobradex-Alcon, Belgium)
and Hydroxypropyl Methylcellulose (Tear Naturale II Alcon, Belgium) four times a day for 4 weeks. Patients
were regularly followed-up at interval of 3 months after
the procedure. Any adverse effect or physical findings
were noted on each visit for a minimum of one year
period. Recurrence of pterygium was defined as an
encroachment of fibrovascular connective tissue across
the limbus and onto the cornea for any distance in the
position of the previous lesion during the follow-up
period.
All data was entered in Statistical Package for Social
Sciences (SPSS) version 16. Baseline characteristics of
patients were analyzed using means and standard
deviations for continuous variables like age while
grading, recurrence and site of pterygium were analyzed
using frequencies and percentages. Pearson Chi-square
test or Fischer Exact test was used to determine the

A total of 120 male patients (120 eyes) aged between 16

and 82 years with mean value of 42.4 1.23 years based
on the inclusion criteria were incorporated in the study
and were followed for a minimum 12 months. While 32
patients in addition to the 120 patients lost to follow-up
during the study period were excluded from the study.
Out of the 120 eyes, 85 eyes (70.8%) were affected by
grade 1 pterygium, 20 eyes (16.7%) had grade 2 and 15
eyes (12.5%) were having grade 3 pterygium. In 109
eyes (95.8%), pterygium was located on the nasal side,
with 10 eyes (3.4%) having it on the temporal side and 1
eye (0.8%) was affected on both sides. Out of 120 eyes
with pterygium, 53 belonged to the right eye and 67 to
the left eye. Baseline characteristics of patients are
shown in Table I.
The recurrence of pterygium was seen in 8 patients
(6.7%) with mean recurrence of time 7.78 + 6.32
months. There was a higher rate of recurrence seen in
subjects with higher grades of corneal involvement
(p = 0.01). The role of pterygium grading in recurrence of
pterygia is shown in Table II.
Table I: Baseline characteristics of patients.
Characteristics of patients

Number of patients
(N = 120)

Frequency
(%)

Right

53

44.2

Left

67

55.8

Affected eye

Site of pterygium
109

90.8

Temporal

Nasal

10

08.3

Central

01

0.83

Grading of pterygium*
Grade 1

85

70.8

Grade 2

20

16.7

Grade 3

15

12.5

Yes

08

06.7

No

112

93.3

Recurrence

*Grading of pterygium has been done as given in methods.

Table II: Potential role of grading and age in pterygium recurrence.

Variable

Recurrence
N (%)
Yes

p-value*
No

Age (years)
Mean std. dev

0.14
42.4 1.23

< 50

07 (9.6)

66 (90.4)

> 50

01 (2.2)

46 (97.8)

Grade 1

01 (1.2)

84 (98.8)

Grade 2

04 (20.2)

16 (79.8)

Grading of pterygium

Grade 3
N = Number of subjects;

Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (2): 120-123

03 (19.8)
* Fischer Exact test;

0.01

12 (80.2)
std. dev = Standard deviation;

min: minutes

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Pir Salim Mahar and Nabeel Manzar

Corneal nebular opacity was the frequent finding seen in

most patients postoperatively with 2 patients developing
conjunctival cyst at the site of excision.

DISCUSSION
Recurrence of pterygium remains an important health
care issue in ophthalmic patients worldwide,1 but
especially in tropical and Asian countries like Pakistan
due to high sun exposure coupled with increased rate of
air pollution and dusty weather. The present study was
motivated by the invariably high recurrence of pterygium
not only in Pakistan but world over.5,15
The recurrence rate of pterygium in the present study
was 6.7%. In a recent trial carried out in Pakistan,
Rahman et al. documented a recurrence of pterygium in
10% of the population. In a prospective study,16 Cheng
et al. observed a recurrence of 7.9% in subjects with
primary pterygia and a recurrence of 19.2% in subjects
with recurrent pterygia.17 In a study carried out by
Narsani et al. 6.97% recurrence was seen in primary
pterygia patients who underwent conjunctival autograft
as compared to 16.13% in patients treated by
intraoperative MMC.18 In contrast, Joseph et al. reported
a recurrence rate of 6.6% with intraoperative MMC as
compared to 13.3% in conjunctival autograft group.19 In
another study carried out by the author (PSM), 25.9%
recurrence was seen in conjunctival autograft group as
compared to 9.4% in the topical MMC group. Hence, the
authors preference for MMC based treatment for
patients was based on his own experience.20 However,
comparison between our study and others is likely to be
biased attributed to the different study population,
setting and criteria used for grading pterygium. Similar
conclusions have been drawn from numerous studies
carried throughout the globe.21,22 In this study, only male
patients with primary pterygium were enrolled for the
study and the intraoperative MMC application time was
also fixed at 3 minutes to limit the influence of factors
implicated in pterygium recurrence.5
A lot of grading systems are currently being used for
grading pterygium but in our study we have used the
grading system based on the size and extent of corneal
involvement by the fibrous pterygium. The same system
of grading is currently being used extensively in Asian
countries and some developed countries as well.3,13
There was a higher tendency of recurrence seen in
participants with higher grades of corneal involvement
with rate of recurrence of 1.2% in group grade 1 as
compared to 20.2% in group grade 2. Similar results
have been obtained in studies across Far East by Tan et
al., where a high rate of recurrence has been associated
with increased fleshiness of the pterygia,23 though the
grading system used in these studies is slightly different,
with translucency and vascularity being used as a
criterion for grading. Nonetheless it is a known fact that
translucency and vascularity increase with the increase
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in the size and extent of corneal involvement by the

pterygium. In contrast, in a study carried out on AsianCanadians using the same grading system as used in
this study, no significant difference in recurrence
between groups for less severe grade pterygia (grade 1)
was found.24 Similarly, Amano et al., using a slightly
extended version of the grading system, as used in this
study, have documented no significant association with
recurrence.25 A higher grade is increasingly being
recognized as a risk factor for recurrence. However, a
uniform grading system with global acceptability for
improving and predicting recurrence outcomes in
patients is currently lacking. Nonetheless, new grading
systems are being developed for documenting and
improving surgical outcomes and cosmesis after
pterygium removal.26,27
While this study fulfills the objective set by the study
protocol for this project of determining the recurrence of
pterygium by its grading method in patients assisted with
intra-operative topical MMC of 0.02%, there remain
certain limitations to this study due to its small sample
size. However, as each patient served as his own
control, any bias due to large inter patient variation or
due to other risk factors is minimized. A large scale
prospective study with appropriate power is recommended for evaluating the role of grading system based
on the size and extent of corneal involvement in cases of
pterygium recurrence.

CONCLUSION
This study found a significant association of recurrence
with higher grade of corneal involvement by the
pterygium. This has important implications as early
excision of pterygium is not practiced even today until
the patient presents with disturbing visual symptoms.
Hence, early excision of pterygium is recommended to
decrease the recurrence rate of pterygium.

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